UNIVERSITI PUTRA MALAYSIA

DIETARY PATTERN AND ITS RELATIONSHIP WITH HEALTH-RELATED FACTORS AMONG PATIENTS WITH

CORONARY ARTERY DISEASE IN AN IRANIAN HOSPITAL

HALEH ESMAILI

FPSK(m) 2013 29

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DIETARY PATTERN AND ITS RELATIONSHIP WITH HEALTH-RELATED FACTORS AMONG PATIENTS WITH

CORONARY ARTERY DISEASE IN AN IRANIAN HOSPITAL

By

HALEH ESMAILI

Thesis Submitted to the School of Graduate Studies, Universiti Putra Malaysia, in Fulfilment of the Requirements for the Degree of Master of Science

April 2013

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DEDICATION

To the meanings of my life:

My dear mother and father

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Abstract of thesis presented to the senate of Universiti Putra Malaysia in fulfilment of the requirement for the degree of Master of Science

DIETARY PATTERN AND ITS RELATIONSHIP WITH HEALTH RELATED FACTORS AMONG PATIENTS WITH CORONARY

ARTERY DISEASE IN IRANIAN HOSPITAL.

By

HALEH ESMAILI

April 2013

Chair: Associate Professor Rokiah Mohd Yusof, PhD

Faculty: Medicine and Health Sciences

The prevalence of coronary artery disease (CAD) has increased in recent times in

developing countries like Iran. In Iran, about 50% of all deaths per year are caused

by CAD and mostly due to behavioral factors such as unhealthy dietary pattern. The

objective of this cross-sectional study was to determine dietary patterns and their

relationship with socio-demographics, health-related factors, biochemical

characteristics, blood pressure and body mass index (BMI) among coronary artery

disease patients in Fatemeh-Zahra Hospital, Sari, Iran.

Data on socio-demographics, smoking status and supplement intake of CAD patients

were collected via a self-administered questionnaire. Dietary pattern was assessed by

semi-quantitative food frequency questionnaire, while the physical activity level was

assessed by using the International Physical Activity Questionnaire. Weight, height

and blood pressure were measured using a weight scale, body meter and blood

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pressure scale (ABN-mercury sphygmomanometer) by trained nurses. The serum

lipid profile was measured using Ebra- auto analyzer by trained technician. The data

of socio-demographic, lipid profile, weight, height and blood pressure were collected

from patients’ record. Data were analyzed by using Statistical Package for Social

Sciences (SPSS) 18.

A total of 250 subjects (52% males and 48% females) who fulfilled the selection

criteria participated in this study. The mean age of the subjects was 59.68±10.26

years and 51.6% of the subjects had low physical activity (total Met-min/wk <600).

Most of the subjects were non-smokers (72.8%) and did not take supplements

(89.2%). Mean of BMI was 26.68 ± 4.42 kg/m² and 43.6% were overweight and

21.6% were obese. Mean of triglyceride, total cholesterol, LDL, and HDL were

183.7 ± 94.8 mg/dl, 179.7 ± 4 2.5 mg/dl, 100.8 ± 31.5 mg/dl, 36.6 ± 9.06 mg/dl

respectively. The mean of systolic blood pressure was 123.5 ± 12.5 mmHg and

diastolic blood pressure was 80.07 ± 8.1 mmHg.

The dietary patterns were identified using factor analysis. The first factor that

explained 12.15% of variances was the traditional pattern. The second pattern, with

12% of variances was the western pattern. The third pattern with 9.06% of variances

was the healthy pattern. Educational level [uneducated (p = 0.007 and primary school

(p = 0.004)], income (p = 0.028), physical activity (p = 0.016) and being a

housewives (p = 0.005) were associated with the traditional pattern. Smoking (p =

0.040), farmers, housewives (p = 0.001) and age (p = 0.000) associated with the

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western pattern. Urban residence (p = 0.015), male (p = 0.049), farmers (p = 0.020)

and income (p = 0.027) were associated with the healthy pattern.

Based on the biochemical characteristics, blood pressure and BMI, the traditional

pattern was significantly associated with increase in systolic and diastolic blood

pressure (� = 0.133 and � = 0.148 respectively) and decrease in LDL (� = -0.127)

and HDL (� = -0.182). The western pattern was significantly associated with increase

in total cholesterol (� = 0.16), LDL (� = 0.13) and BMI (� = 0.12). The healthy

pattern was significantly associated with decrease of TG (� = -0.123), BMI (� = -

0.170), systolic (� = -0.130) and diastolic blood pressure (� = -0.135).

In conclusion, these findings indicated that the healthy pattern was practiced by less

number of subjects with percentages of variance lower than other patterns. Also, this

study provided insight into the socio-demographic and health-related factors that are

related to dietary patterns of coronary artery disease and factors that are influenced

by dietary patterns. This study can also be used to strengthen public health strategies

that aim to improve dietary intake for primary and secondary prevention of CAD.

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Abstrak tesis yang dikemukakan kepada Senta Universiti Putra Malaysia sebagai memenuhi keperluan untuk ijazah Master Sains

POLA DIET DAN PERKAITANNYA DENGAN FAKTOR KESIHATAN DALAM KALANGAN PESAKIT PENYAKIT KORONARI ARTERI DI

HOSPITAL IRAN.

Oleh

HALEH ESMAILI

April 2013

Pengerusi: Profesor Madya Rokiah Mohd Yusof, PhD

Fakulti: Perubatan dan Sains Kesihatan

Prevalens penyakit koronari arteri (CAD) telah meningkat masakini di negara-negara

membangun seperti Iran. Di Iran, lebihkurang 50% daripada kematian per tahun

disebabkan oleh CAD dan kebanyakanya disebabkan faktor tingkahlaku seperti pola

diet yang tidak sihat. Objektif kajian garis lintang ini adalah untuk menentukan pola

diet dan perkaitannya dengan faktor sosio-demografi, faktor kesihatan, ciri biokimia,

tekanan darah dan index jisim tubuh (IJT) dalam kalangan pesakit CAD di hospital

Fatemeh-Zahra, Sari, Iran.

Data sosio-demografi, status merokok dan pengambilan suplemen di kalangan

pesakit CAD telah diperolehi melalui borang soal-selidik. Pola diet telah ditentukan

melalui borang kekerapan makanan semi-kuantitatif, manakala tahap aktiviti fizikal

telah ditentukan menggunakan borang soal-selidik aktiviti fizikal antarabangsa.

Berat, tinggi dan tekanan darah telah diukur oleh jururawat terlatih, menggunakan

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timbang (Seca), meter tubuh dan alat tekanan darah (ABN-mercury

sphygmomanometer). Profil serum lipid telah diukur menggunakan Ebra-auto

analyzer oleh teknician terlatih. Semua data di perolehi daripada rekod pesakit. Data

telah dianalisis menggunakan Statistical Package for Social Sciences (SPSS) versi

18.

Seramai 250 subjek (52% lelaki dan 48% perempuan) yang telah memenuhi kriteria

pemilihan bagi peserta telah terlibat dalam kajian ini. Min umur subjek adalah

59.68±10.26 tahun dan 51.6% daripada subjek mempunyai rendah aktiviti fizikal

(jumlah Met-min/minggu<600). Kebanyakkan subjek tidak merokok (72.8%) dan

tidak mengambil suplemen (89.2%). Min bagi IJT adalah 26.68 ± 4.42 kg/m² dan

43.6% adalah lebih beratbadan dan 21.6% adalah obes. Min TG, jumlah kolesterol,

LDL, dan HDL adalah 183.7 ± 94.8 mg/dl, 179.7 ±42.5 mg/dl, 100.8 ± 31.5 mg/dl,

36.6 ± 9.06 mg/dl masing-masing. Min tekanan darah sistolik adalah 123.5 ± 12.5

mmHg dan tekanan darah diastolik adalah 80.07 ± 8.1 mmHg.

Pola diet telah dikenalpasti menggunakan analisis faktor. Faktor pertama yang

menerangkan 12.15% varians adalah pola tradisional. Pola kedua, dengan 12%

varians adalah pola barat. Pola ketiga dengan 9.06% varians adalah pola sihat.

Tahap pendidikan (tidak berpendidikan (p = 0.007) dan sekolah rendah (p = 0.004),

pendapatan (p = 0.028), aktiviti fizikal (p = 0.016) dan surirumah (p = 0.005) adalah

berkait secara dengan pola tradisional. Merokok (p = 0.040), petani, surirumah (p =

0.001), dan umur (p = 0.000) berkait dengan pola barat. Tinggal di bandar (p =

0.015), lelaki (p = 0.049), petani (p = 0.020) dan pendapatan (p = 0.027) berkait

dengan pola sihat.

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Berasaskan ciri-ciri biokimia, tekanan darah dan BMI, pola tradisional adalah

berkait secara signifikan dengan meningkat tekanan darah sistolik dan diastolik (� =

0.133 dan � = 0.148 masing-masing) dan kurang bagi LDL (� = -0.127) dan HDL (�

= -0.182). Pola barat secara signifikan berkait dengan bertambah paras jumlah

kolesterol (� = 0.16), LDL (� = 0.13) dan BMI (� = 0.12). Pola sihat secara

signifikan berkait dengan berkurangan paras TG (� = -0.123), BMI (� = -0.170),

tekanan darah sistolik (B = -0.130) dan diastolik (� = -0.135).

Kesimpulannya, penemuan ini menunjukkan bahawa pola sihat telah diamalkan oleh

kurang bilangan subjek dengan peratus varians rendah daripada pola-pola yang lain.

Kajian ini juga, telah memberi pendedahan kepada faktor sosio-demografi dan faktor

yang berkait dengan kesihatan dengan pola diet pesakit koronari arteri dan faktor

yang mempengaruhi pola diet. Kajian ini juga boleh digunakan untuk

memperkukuhkan strategi kesihatan awam yang bertujuan untuk memperbaiki

pengambilan diet bagi pencegahan utama dan sekunder penyakit CAD.

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ACKNOWLEDGEMENTS

I would like to express my profound gratitude and deepest appreciation to my

supervisor Associate Professor Dr. Rokiah Mohd Yusof for her help, guidance

and encouragement throughout the duration of the study and as a chairperson by

providing excellent recommendation and feedback. Gratitude is also extended to

my committee members Associate Professor Dr. Hazizi Abu Saad for sharing his

knowledge, guidance and especially for his encouragement, advice and ongoing

suggestions and Associate Professor Dr. Ali Ghaemian for his assistance and

constant willingness to provide any help he could with this thesis and for

allowing me to assess the patients.

A token of gratitude and sincere thanks to all nurses in Fatemeh-Zahra hospital,

especially those in the Catheterization Ward for their cooperation, assistance and

kindness during the interviews as well as all patients who participated in this

study.

Finally, I am forever in debted to my parents (Elaheh Serati and Esmail Esmaili)

and my sisters (Laleh and Hilda) for their understanding, patience, endless

support and encouragement during my work. They made it possible for me

successfully compete what I had to do.

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I certify that a Thesis Examination Committee has met on (29 April 2013) to conduct the final examination of HALEH ESMAILI on her thesis entitled “DIETARY PATTERN AND ITS RELATIONSHIP WITH HEALTH RELATED FACTORS AMONG PATIENTS WITH CORONARY ARTERY DISEASE IN AN IRANIAN HOSPITAL” in accordance with the universities and University Colleges Act 1971 and the Constitution of the Universiti Putra Malaysia [P.U.(A) 106] 15 March 1998. The committee recommends that the student be awarded the Master of Science. Members of the Thesis Examination Committee were as follows:

Mohd Sokhini bin Mutalib, PhD Associate Professor Faculty of Medicine and Health Sciences Universiti Putra Malaysia (Chairman) Rosita binti Jamaluddin, PhD Senior Lecturer Faculty of Medicine and Health Sciences Universiti Putra Malaysia (Internal Examiner) Zaitun bt Yassin 2, PhD Associate Professor Faculty of Medicine and Health Sciences Universiti Putra Malaysia (Internal Examiner) Poh Bee Koon, PhD Professor Faculty of Allied Sciences Universiti Kebangsaan Malaysia (External Examiner)

NORITAH OMAR, PhD Associate Professor and Deputy Dean School of Graduate Studies Universiti Putra Malaysia Date:

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The thesis was submitted to the Senate of Universiti Putra Malaysia and has been accepted as fulfillment of the requirement for the degree of Master of Science. The members of the supervisory Committee were as follows: Rokiah Mohd Yusof, PhD Associate Professor Faculty of Medicine and Health Sciences Universiti Putra Malaysia (Chairman)

Hazizi Abu Saad, PhD Associate Professor

Faculty of Medicine and Health Sciences Universiti Putra Malaysia (Member)

Ali Ghaemian, MD Associate Professor Faculty of Medical Sciences Mazandaran University (Member)

BUJANG BIM KIM HUAT, PhD Professor and Dean School of Graduate Studies Universiti Putra Malaysia

Date:

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DECLARATION

I declare that the thesis is my original work except for quotations and citations which have been duly acknowledged. I also, declare that it has not been previously, and is not concurrently, submitted for any other degree at Universiti Putra Malaysia or at any other institutions.

HALEH ESMAILI

Date: 29 April 2013

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TABLE OF CONTENTS Page

DEDICATION ii ABSRTACT iii ABSTRAK vi ACKNOWLEDGEMENTS ix APPROVAL x DECLARATION xii LIST OF TABLES xvi LIST OF FIGURES xix LIST OF ABBREVITIONS xx CHAPTER 1.� INTRODUCTION 1�

1.1� Background 1�

1.2� Problem Statement 4�

1.3� Research Questions 6�

1.4� Significance of the Study 6�

1.5� Objective 7�

1.5.1�Main Objective 7�

1.5.2�Specific Objectives 7�

1.6� Null Hypothesis 8�

1.7� Conceptual Framework of Study 8�

2.� LITERATURE REVIEW 11�

2.1� Overview 11�

2.1.1�Dietary Pattern in Epidemiology 11�

2.2� Coronary Artery Disease in Iran 12�

2.3� Dietary Pattern and CAD 13�

2.3.1�Primary Prevention of CAD 13�

2.3.2�Secondary Prevention 16�

2.4� Dietary Patterns in Iran 17�

2.5� Factors Influencing Dietary Pattern 20�

2.5.1�Socio-demographic Factors 20�

2.5.2�Health Related Factors 26�

2.6� Effect of Dietary Patterns 30�

2.6.1�Serum Lipid Profile 30�

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2.6.2�Blood Pressure 33�

2.6.3�Body Mass Index (BMI) 34�

3.� METHODOLOGY 37�

3.1� Study Location and Design 37�

3.1.1�Study Location 37�

3.1.2�Study Design 39�

3.2� Population and Sampling 39�

3.2.1�Sample Size 39�

3.2.2�Recruitment Procedure 40�

3.2.3� Inclusion and Exclusion Criteria 42�

3.3� Instrument and Assessment 43�

3.3.1�Socio-demographic and Personal Information Questionnaire 43�

3.3.2�Health related factors Questionnaire 44�

3.3.3�Anthropometric Measurement 45�

3.3.4�Serum Lipid Profile and Blood Pressure Measurement 46�

3.3.5�Food Frequency Questionnaire (FFQ) 48�

3.4� Food Grouping 48�

3.5� Pre-test 50�

3.6� Statistical Analysis 50�

3.6.1�Preliminary Analysis 50�

3.6.2�Factor Analysis and Dietary Pattern 51�

3.6.3�Data Analysis 53�

3.6.4�Quintiles 53�

3.7� Pre-test 54�

4.� RESULTS 55�

4.1� Socio-demographic Characteristics of Subjects 55�

4.2� Health related Characteristics 57�

4.2.1�Physical Activity 57�

4.2.2�Smoking (Tobacco Use) 60�

4.2.3�Supplement Intakes 62�

4.3� Anthropometric Characteristics 64�

4.3.1�Height and Weight 64�

4.3.2�BMI 64�

4.4� Biochemical Characteristics 66�

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4.4.1�Lipid Profile 66�

4.4.2�Blood Pressure 68�

4.5� Analysis to Determine Dietary Pattern 70�

4.6� Quintiles of Dietary Patterns 73�

4.7� Factors Related to Dietary Patterns Using General Linear Model 82�

4.8� Dietary Pattern and Serum Lipid Profile, Blood Pressure and BMI 84�

5. DISCUSSION 88�

4.9� BMI and Prevalence of Obesity 88�

4.10� Biochemical Characteristics 91�

4.11� Dietary Patterns 92�

4.12� Socio-demographic and Health Related Factors and Dietary Patterns 94�

4.13� Relationship between Dietary Patterns and Lipid profiles, Blood Pressure and BMI 97�

6. CONCLUSION AND RECOMMENDATION 105�

4.14� Conclusion 105�

4.15� Recommendations 107�

4.16� Limitations of the Study 108�

REFERENCES 111 APPENDICES 128 BIODATA OF STUDENT 169 LIST OF PUBLICATIONS 170